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            <div id="rn_SelectionInput_7" class="rn_SelectionInput rn_Input rn_Radio">
            <fieldset>
            <legend id="rn_SelectionInput_7_Label" class="rn_Label">
                Escalated Gift Card - Devalue                            </legend>
                    <input type="radio" name="Incident.CustomFields.c.escalated_gift_card_devalue" id="rn_SelectionInput_7_Incident.CustomFields.c.escalated_gift_card_devalue_1"  value="1"/>
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                Escalated - Catering Sales                            </legend>
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            Yes                        </label>
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            No                        </label>
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        <div id="rn_DateInput_11" class="rn_DateInput rn_Input">
<fieldset>
    <legend id="rn_DateInput_11_Legend" class="rn_Label">PA Team Escalated Team Assign            </legend>
            <label for="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Month" class="rn_ScreenReaderOnly">Month</label>
    <select id="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Month" name="Incident.CustomFields.c.pa_team_escalated_team_assign.month">
        <option value=''>--</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
            </select>
                    <label for="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Day" class="rn_ScreenReaderOnly">Day</label>
    <select id="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Day" name="Incident.CustomFields.c.pa_team_escalated_team_assign.day">
        <option value=''>--</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
                <option value="24" >24</option>
                <option value="25" >25</option>
                <option value="26" >26</option>
                <option value="27" >27</option>
                <option value="28" >28</option>
                <option value="29" >29</option>
                <option value="30" >30</option>
                <option value="31" >31</option>
            </select>
                <label for="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Year" class="rn_ScreenReaderOnly">Year</label>
    <select id="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Year" name="Incident.CustomFields.c.pa_team_escalated_team_assign.year">
        <option value=''>--</option>
                <option value="2017" >2017</option>
                <option value="2016" >2016</option>
                <option value="2015" >2015</option>
                <option value="2014" >2014</option>
                <option value="2013" >2013</option>
                <option value="2012" >2012</option>
                <option value="2011" >2011</option>
                <option value="2010" >2010</option>
                <option value="2009" >2009</option>
                <option value="2008" >2008</option>
                <option value="2007" >2007</option>
                <option value="2006" >2006</option>
                <option value="2005" >2005</option>
                <option value="2004" >2004</option>
                <option value="2003" >2003</option>
                <option value="2002" >2002</option>
                <option value="2001" >2001</option>
                <option value="2000" >2000</option>
                <option value="1999" >1999</option>
                <option value="1998" >1998</option>
                <option value="1997" >1997</option>
                <option value="1996" >1996</option>
                <option value="1995" >1995</option>
                <option value="1994" >1994</option>
                <option value="1993" >1993</option>
                <option value="1992" >1992</option>
                <option value="1991" >1991</option>
                <option value="1990" >1990</option>
                <option value="1989" >1989</option>
                <option value="1988" >1988</option>
                <option value="1987" >1987</option>
                <option value="1986" >1986</option>
                <option value="1985" >1985</option>
                <option value="1984" >1984</option>
                <option value="1983" >1983</option>
                <option value="1982" >1982</option>
                <option value="1981" >1981</option>
                <option value="1980" >1980</option>
                <option value="1979" >1979</option>
                <option value="1978" >1978</option>
                <option value="1977" >1977</option>
                <option value="1976" >1976</option>
                <option value="1975" >1975</option>
                <option value="1974" >1974</option>
                <option value="1973" >1973</option>
                <option value="1972" >1972</option>
                <option value="1971" >1971</option>
                <option value="1970" >1970</option>
            </select>
                <label for="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Hour" class="rn_ScreenReaderOnly">Hour</label>
    <select id="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Hour" name="Incident.CustomFields.c.pa_team_escalated_team_assign.hour">
        <option value=''>--</option>
                <option value="0" >0</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
            </select>
        <label for="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Minute" class="rn_ScreenReaderOnly">Minute</label>
    <select id="rn_DateInput_11_Incident.CustomFields.c.pa_team_escalated_team_assign_Minute" name="Incident.CustomFields.c.pa_team_escalated_team_assign.minute">
        <option value=''>--</option>
                <option value="0" >0</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
                <option value="24" >24</option>
                <option value="25" >25</option>
                <option value="26" >26</option>
                <option value="27" >27</option>
                <option value="28" >28</option>
                <option value="29" >29</option>
                <option value="30" >30</option>
                <option value="31" >31</option>
                <option value="32" >32</option>
                <option value="33" >33</option>
                <option value="34" >34</option>
                <option value="35" >35</option>
                <option value="36" >36</option>
                <option value="37" >37</option>
                <option value="38" >38</option>
                <option value="39" >39</option>
                <option value="40" >40</option>
                <option value="41" >41</option>
                <option value="42" >42</option>
                <option value="43" >43</option>
                <option value="44" >44</option>
                <option value="45" >45</option>
                <option value="46" >46</option>
                <option value="47" >47</option>
                <option value="48" >48</option>
                <option value="49" >49</option>
                <option value="50" >50</option>
                <option value="51" >51</option>
                <option value="52" >52</option>
                <option value="53" >53</option>
                <option value="54" >54</option>
                <option value="55" >55</option>
                <option value="56" >56</option>
                <option value="57" >57</option>
                <option value="58" >58</option>
                <option value="59" >59</option>
            </select>
</fieldset>
</div>
        <div id="rn_DateInput_13" class="rn_DateInput rn_Input">
<fieldset>
    <legend id="rn_DateInput_13_Legend" class="rn_Label">PA Team Initial Tracking            </legend>
            <label for="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Month" class="rn_ScreenReaderOnly">Month</label>
    <select id="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Month" name="Incident.CustomFields.c.pa_team_initial_tracking.month">
        <option value=''>--</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
            </select>
                    <label for="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Day" class="rn_ScreenReaderOnly">Day</label>
    <select id="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Day" name="Incident.CustomFields.c.pa_team_initial_tracking.day">
        <option value=''>--</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
                <option value="24" >24</option>
                <option value="25" >25</option>
                <option value="26" >26</option>
                <option value="27" >27</option>
                <option value="28" >28</option>
                <option value="29" >29</option>
                <option value="30" >30</option>
                <option value="31" >31</option>
            </select>
                <label for="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Year" class="rn_ScreenReaderOnly">Year</label>
    <select id="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Year" name="Incident.CustomFields.c.pa_team_initial_tracking.year">
        <option value=''>--</option>
                <option value="2017" >2017</option>
                <option value="2016" >2016</option>
                <option value="2015" >2015</option>
                <option value="2014" >2014</option>
                <option value="2013" >2013</option>
                <option value="2012" >2012</option>
                <option value="2011" >2011</option>
                <option value="2010" >2010</option>
                <option value="2009" >2009</option>
                <option value="2008" >2008</option>
                <option value="2007" >2007</option>
                <option value="2006" >2006</option>
                <option value="2005" >2005</option>
                <option value="2004" >2004</option>
                <option value="2003" >2003</option>
                <option value="2002" >2002</option>
                <option value="2001" >2001</option>
                <option value="2000" >2000</option>
                <option value="1999" >1999</option>
                <option value="1998" >1998</option>
                <option value="1997" >1997</option>
                <option value="1996" >1996</option>
                <option value="1995" >1995</option>
                <option value="1994" >1994</option>
                <option value="1993" >1993</option>
                <option value="1992" >1992</option>
                <option value="1991" >1991</option>
                <option value="1990" >1990</option>
                <option value="1989" >1989</option>
                <option value="1988" >1988</option>
                <option value="1987" >1987</option>
                <option value="1986" >1986</option>
                <option value="1985" >1985</option>
                <option value="1984" >1984</option>
                <option value="1983" >1983</option>
                <option value="1982" >1982</option>
                <option value="1981" >1981</option>
                <option value="1980" >1980</option>
                <option value="1979" >1979</option>
                <option value="1978" >1978</option>
                <option value="1977" >1977</option>
                <option value="1976" >1976</option>
                <option value="1975" >1975</option>
                <option value="1974" >1974</option>
                <option value="1973" >1973</option>
                <option value="1972" >1972</option>
                <option value="1971" >1971</option>
                <option value="1970" >1970</option>
            </select>
                <label for="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Hour" class="rn_ScreenReaderOnly">Hour</label>
    <select id="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Hour" name="Incident.CustomFields.c.pa_team_initial_tracking.hour">
        <option value=''>--</option>
                <option value="0" >0</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
            </select>
        <label for="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Minute" class="rn_ScreenReaderOnly">Minute</label>
    <select id="rn_DateInput_13_Incident.CustomFields.c.pa_team_initial_tracking_Minute" name="Incident.CustomFields.c.pa_team_initial_tracking.minute">
        <option value=''>--</option>
                <option value="0" >0</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
                <option value="24" >24</option>
                <option value="25" >25</option>
                <option value="26" >26</option>
                <option value="27" >27</option>
                <option value="28" >28</option>
                <option value="29" >29</option>
                <option value="30" >30</option>
                <option value="31" >31</option>
                <option value="32" >32</option>
                <option value="33" >33</option>
                <option value="34" >34</option>
                <option value="35" >35</option>
                <option value="36" >36</option>
                <option value="37" >37</option>
                <option value="38" >38</option>
                <option value="39" >39</option>
                <option value="40" >40</option>
                <option value="41" >41</option>
                <option value="42" >42</option>
                <option value="43" >43</option>
                <option value="44" >44</option>
                <option value="45" >45</option>
                <option value="46" >46</option>
                <option value="47" >47</option>
                <option value="48" >48</option>
                <option value="49" >49</option>
                <option value="50" >50</option>
                <option value="51" >51</option>
                <option value="52" >52</option>
                <option value="53" >53</option>
                <option value="54" >54</option>
                <option value="55" >55</option>
                <option value="56" >56</option>
                <option value="57" >57</option>
                <option value="58" >58</option>
                <option value="59" >59</option>
            </select>
</fieldset>
</div>
        <div id="rn_DateInput_15" class="rn_DateInput rn_Input">
<fieldset>
    <legend id="rn_DateInput_15_Legend" class="rn_Label">PA Team Analyst Assignment            </legend>
            <label for="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Month" class="rn_ScreenReaderOnly">Month</label>
    <select id="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Month" name="Incident.CustomFields.c.pa_team_analyst_assignment.month">
        <option value=''>--</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
            </select>
                    <label for="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Day" class="rn_ScreenReaderOnly">Day</label>
    <select id="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Day" name="Incident.CustomFields.c.pa_team_analyst_assignment.day">
        <option value=''>--</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
                <option value="24" >24</option>
                <option value="25" >25</option>
                <option value="26" >26</option>
                <option value="27" >27</option>
                <option value="28" >28</option>
                <option value="29" >29</option>
                <option value="30" >30</option>
                <option value="31" >31</option>
            </select>
                <label for="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Year" class="rn_ScreenReaderOnly">Year</label>
    <select id="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Year" name="Incident.CustomFields.c.pa_team_analyst_assignment.year">
        <option value=''>--</option>
                <option value="2017" >2017</option>
                <option value="2016" >2016</option>
                <option value="2015" >2015</option>
                <option value="2014" >2014</option>
                <option value="2013" >2013</option>
                <option value="2012" >2012</option>
                <option value="2011" >2011</option>
                <option value="2010" >2010</option>
                <option value="2009" >2009</option>
                <option value="2008" >2008</option>
                <option value="2007" >2007</option>
                <option value="2006" >2006</option>
                <option value="2005" >2005</option>
                <option value="2004" >2004</option>
                <option value="2003" >2003</option>
                <option value="2002" >2002</option>
                <option value="2001" >2001</option>
                <option value="2000" >2000</option>
                <option value="1999" >1999</option>
                <option value="1998" >1998</option>
                <option value="1997" >1997</option>
                <option value="1996" >1996</option>
                <option value="1995" >1995</option>
                <option value="1994" >1994</option>
                <option value="1993" >1993</option>
                <option value="1992" >1992</option>
                <option value="1991" >1991</option>
                <option value="1990" >1990</option>
                <option value="1989" >1989</option>
                <option value="1988" >1988</option>
                <option value="1987" >1987</option>
                <option value="1986" >1986</option>
                <option value="1985" >1985</option>
                <option value="1984" >1984</option>
                <option value="1983" >1983</option>
                <option value="1982" >1982</option>
                <option value="1981" >1981</option>
                <option value="1980" >1980</option>
                <option value="1979" >1979</option>
                <option value="1978" >1978</option>
                <option value="1977" >1977</option>
                <option value="1976" >1976</option>
                <option value="1975" >1975</option>
                <option value="1974" >1974</option>
                <option value="1973" >1973</option>
                <option value="1972" >1972</option>
                <option value="1971" >1971</option>
                <option value="1970" >1970</option>
            </select>
                <label for="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Hour" class="rn_ScreenReaderOnly">Hour</label>
    <select id="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Hour" name="Incident.CustomFields.c.pa_team_analyst_assignment.hour">
        <option value=''>--</option>
                <option value="0" >0</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
            </select>
        <label for="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Minute" class="rn_ScreenReaderOnly">Minute</label>
    <select id="rn_DateInput_15_Incident.CustomFields.c.pa_team_analyst_assignment_Minute" name="Incident.CustomFields.c.pa_team_analyst_assignment.minute">
        <option value=''>--</option>
                <option value="0" >0</option>
                <option value="1" >1</option>
                <option value="2" >2</option>
                <option value="3" >3</option>
                <option value="4" >4</option>
                <option value="5" >5</option>
                <option value="6" >6</option>
                <option value="7" >7</option>
                <option value="8" >8</option>
                <option value="9" >9</option>
                <option value="10" >10</option>
                <option value="11" >11</option>
                <option value="12" >12</option>
                <option value="13" >13</option>
                <option value="14" >14</option>
                <option value="15" >15</option>
                <option value="16" >16</option>
                <option value="17" >17</option>
                <option value="18" >18</option>
                <option value="19" >19</option>
                <option value="20" >20</option>
                <option value="21" >21</option>
                <option value="22" >22</option>
                <option value="23" >23</option>
                <option value="24" >24</option>
                <option value="25" >25</option>
                <option value="26" >26</option>
                <option value="27" >27</option>
                <option value="28" >28</option>
                <option value="29" >29</option>
                <option value="30" >30</option>
                <option value="31" >31</option>
                <option value="32" >32</option>
                <option value="33" >33</option>
                <option value="34" >34</option>
                <option value="35" >35</option>
                <option value="36" >36</option>
                <option value="37" >37</option>
                <option value="38" >38</option>
                <option value="39" >39</option>
                <option value="40" >40</option>
                <option value="41" >41</option>
                <option value="42" >42</option>
                <option value="43" >43</option>
                <option value="44" >44</option>
                <option value="45" >45</option>
                <option value="46" >46</option>
                <option value="47" >47</option>
                <option value="48" >48</option>
                <option value="49" >49</option>
                <option value="50" >50</option>
                <option value="51" >51</option>
                <option value="52" >52</option>
                <option value="53" >53</option>
                <option value="54" >54</option>
                <option value="55" >55</option>
                <option value="56" >56</option>
                <option value="57" >57</option>
                <option value="58" >58</option>
                <option value="59" >59</option>
            </select>
</fieldset>
</div>
        <div id="rn_TextInput_17" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_17_LabelContainer">
        <label for="rn_TextInput_17_Incident.CustomFields.c.pa_external_reference_nbr" id="rn_TextInput_17_Label" class="rn_Label">
        PA External Reference                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                        </label>
    </div>
        <input type="text" id="rn_TextInput_17_Incident.CustomFields.c.pa_external_reference_nbr" name="Incident.CustomFields.c.pa_external_reference_nbr" class="rn_Text" maxlength='20'  placeholder=" "/>
    </div>
        <div id="rn_SelectionInput_19" class="rn_SelectionInput rn_Input rn_Radio">
            <fieldset>
            <legend id="rn_SelectionInput_19_Label" class="rn_Label">
                PA Tracking Monitor Control                            </legend>
                    <input type="radio" name="Incident.CustomFields.c.pa_tracking_monitor_control" id="rn_SelectionInput_19_Incident.CustomFields.c.pa_tracking_monitor_control_1"  value="1"/>
            <label for="rn_SelectionInput_19_Incident.CustomFields.c.pa_tracking_monitor_control_1">
            Yes                        </label>
                    <input type="radio" name="Incident.CustomFields.c.pa_tracking_monitor_control" id="rn_SelectionInput_19_Incident.CustomFields.c.pa_tracking_monitor_control_0" checked="checked" value="0"/>
            <label for="rn_SelectionInput_19_Incident.CustomFields.c.pa_tracking_monitor_control_0">
            No                        </label>
                        </fieldset>
    </div>
        <div id="rn_SelectionInput_21" class="rn_SelectionInput rn_Input rn_Radio">
            <fieldset>
            <legend id="rn_SelectionInput_21_Label" class="rn_Label">
                Gift Card Agent                            </legend>
                    <input type="radio" name="Incident.CustomFields.c.gift_card_super_agent" id="rn_SelectionInput_21_Incident.CustomFields.c.gift_card_super_agent_1"  value="1"/>
            <label for="rn_SelectionInput_21_Incident.CustomFields.c.gift_card_super_agent_1">
            Yes                        </label>
                    <input type="radio" name="Incident.CustomFields.c.gift_card_super_agent" id="rn_SelectionInput_21_Incident.CustomFields.c.gift_card_super_agent_0"  value="0"/>
            <label for="rn_SelectionInput_21_Incident.CustomFields.c.gift_card_super_agent_0">
            No                        </label>
                        </fieldset>
    </div>
        <div id="rn_SelectionInput_23" class="rn_SelectionInput rn_Input">
    <div id="rn_SelectionInput_23_LabelContainer">
        <label for="rn_SelectionInput_23_Incident.CustomFields.c.gift_card_request_type" id="rn_SelectionInput_23_Label" class="rn_Label">Gift Card Request Type                        </label>
    </div>
    <select id="rn_SelectionInput_23_Incident.CustomFields.c.gift_card_request_type" name="Incident.CustomFields.c.gift_card_request_type">
            <option value="">--</option>
                            <option value="591" >Frozen Card</option>
                    <option value="592" >Mag Swipe Restricted</option>
                    <option value="593" >Other</option>
                </select>
    </div>
        <div id="rn_SelectionInput_25" class="rn_SelectionInput rn_Input">
    <div id="rn_SelectionInput_25_LabelContainer">
        <label for="rn_SelectionInput_25_Incident.CustomFields.c.gift_card_action" id="rn_SelectionInput_25_Label" class="rn_Label">Gift Card Action                        </label>
    </div>
    <select id="rn_SelectionInput_25_Incident.CustomFields.c.gift_card_action" name="Incident.CustomFields.c.gift_card_action">
            <option value="">--</option>
                            <option value="589" >Devalue</option>
                    <option value="590" >Add Value</option>
                    <option value="594" >Devalue and Add Value</option>
                    <option value="595" >Combine Cards</option>
                </select>
    </div>
        <div id="rn_SelectionInput_27" class="rn_SelectionInput rn_Input">
    <div id="rn_SelectionInput_27_LabelContainer">
        <label for="rn_SelectionInput_27_Incident.CustomFields.c.gift_card_issuer_person" id="rn_SelectionInput_27_Label" class="rn_Label">Gift Card Issuer (person)                        </label>
    </div>
    <select id="rn_SelectionInput_27_Incident.CustomFields.c.gift_card_issuer_person" name="Incident.CustomFields.c.gift_card_issuer_person">
            <option value="">--</option>
                            <option value="588" selected="selected">Jane</option>
                </select>
    </div>
        <div id="rn_TextInput_29" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_29_LabelContainer">
        <label for="rn_TextInput_29_Incident.CustomFields.c.gift_card_appeasement_amt" id="rn_TextInput_29_Label" class="rn_Label">
        Gift Card Appeasement $                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                        </label>
    </div>
        <input type="text" id="rn_TextInput_29_Incident.CustomFields.c.gift_card_appeasement_amt" name="Incident.CustomFields.c.gift_card_appeasement_amt" class="rn_Text" maxlength='10'  placeholder=" "/>
    </div>
        <div id="rn_TextInput_31" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_31_LabelContainer">
        <label for="rn_TextInput_31_Incident.CustomFields.c.gift_card_amount_new" id="rn_TextInput_31_Label" class="rn_Label">
        Gift Card Amount (new)                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                        </label>
    </div>
        <input type="text" id="rn_TextInput_31_Incident.CustomFields.c.gift_card_amount_new" name="Incident.CustomFields.c.gift_card_amount_new" class="rn_Text" maxlength='10'  placeholder=" "/>
    </div>
        <div id="rn_TextInput_33" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_33_LabelContainer">
        <label for="rn_TextInput_33_Incident.CustomFields.c.gift_card_new_card" id="rn_TextInput_33_Label" class="rn_Label">
        Gift Card - New Card #                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                        </label>
    </div>
        <input type="text" id="rn_TextInput_33_Incident.CustomFields.c.gift_card_new_card" name="Incident.CustomFields.c.gift_card_new_card" class="rn_Text" maxlength='19'  placeholder=" "/>
    </div>
        <div id="rn_TextInput_35" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_35_LabelContainer">
        <label for="rn_TextInput_35_Incident.CustomFields.c.gift_card_box_number" id="rn_TextInput_35_Label" class="rn_Label">
        Gift Card Box #                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                        </label>
    </div>
        <input type="text" id="rn_TextInput_35_Incident.CustomFields.c.gift_card_box_number" name="Incident.CustomFields.c.gift_card_box_number" class="rn_Text" maxlength='20'  placeholder=" "/>
    </div>
        <div id="rn_TextInput_37" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_37_LabelContainer">
        <label for="rn_TextInput_37_Incident.CustomFields.c.gift_card_frozen_amount" id="rn_TextInput_37_Label" class="rn_Label">
        Gift Card Amount (frozen)                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                        </label>
    </div>
        <input type="text" id="rn_TextInput_37_Incident.CustomFields.c.gift_card_frozen_amount" name="Incident.CustomFields.c.gift_card_frozen_amount" class="rn_Text" maxlength='10'  placeholder=" "/>
    </div>
        <div id="rn_TextInput_39" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_39_LabelContainer">
        <label for="rn_TextInput_39_Incident.CustomFields.c.gift_card_frozen_card_number" id="rn_TextInput_39_Label" class="rn_Label">
        Gift Card Frozen Card #                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                        </label>
    </div>
        <input type="text" id="rn_TextInput_39_Incident.CustomFields.c.gift_card_frozen_card_number" name="Incident.CustomFields.c.gift_card_frozen_card_number" class="rn_Text" maxlength='19'  placeholder=" "/>
    </div>
        <div id="rn_TextInput_41" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_41_LabelContainer">
        <label for="rn_TextInput_41_Incident.CustomFields.c.gift_card_issuing_location" id="rn_TextInput_41_Label" class="rn_Label">
        Gift Card Issuing Location                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                        </label>
    </div>
        <input type="text" id="rn_TextInput_41_Incident.CustomFields.c.gift_card_issuing_location" name="Incident.CustomFields.c.gift_card_issuing_location" class="rn_Text" maxlength='30'  placeholder=" "/>
    </div>
        <div id="rn_SelectionInput_43" class="rn_SelectionInput rn_Input">
    <div id="rn_SelectionInput_43_LabelContainer">
        <label for="rn_SelectionInput_43_Incident.CustomFields.c.chat_type" id="rn_SelectionInput_43_Label" class="rn_Label">Chat Topic                            <span class="rn_ScreenReaderOnly">Please select the Chat topic that best fits the issue</span>
                </label>
    </div>
    <select id="rn_SelectionInput_43_Incident.CustomFields.c.chat_type" name="Incident.CustomFields.c.chat_type">
            <option value="">--</option>
                            <option value="96" >Online Ordering Support</option>
                    <option value="308" >Catering Website Support</option>
                    <option value="309" >Account Support</option>
                </select>
    </div>
        <div id="rn_TextInput_45" class="rn_TextInput rn_TextInput rn_Input">
    <div id="rn_TextInput_45_LabelContainer">
        <label for="rn_TextInput_45_Incident.CustomFields.c.last_4_digits" id="rn_TextInput_45_Label" class="rn_Label">
        last 4 digits                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
                            <span class="rn_ScreenReaderOnly">Enter the last 4 digits of the customer's credit card</span>
                </label>
    </div>
        <input type="text" id="rn_TextInput_45_Incident.CustomFields.c.last_4_digits" name="Incident.CustomFields.c.last_4_digits" class="rn_Text" maxlength='4'  placeholder=" "/>
    </div>
        <div id="rn_SelectionInput_47" class="rn_SelectionInput rn_Input rn_Radio">
            <fieldset>
            <legend id="rn_SelectionInput_47_Label" class="rn_Label">
                Which location did you visit?                            </legend>
                    <input type="radio" name="Incident.CustomFields.c.pertains_to_cafe" id="rn_SelectionInput_47_Incident.CustomFields.c.pertains_to_cafe_1"  value="1"/>
            <label for="rn_SelectionInput_47_Incident.CustomFields.c.pertains_to_cafe_1">
            Yes                            <span class="rn_ScreenReaderOnly">Does your question or comment pertain to a specific bakery-cafe?  If it does, please select this option so we can be sure we are addressing the correct bakery-cafe.</span>
                        </label>
                    <input type="radio" name="Incident.CustomFields.c.pertains_to_cafe" id="rn_SelectionInput_47_Incident.CustomFields.c.pertains_to_cafe_0" checked="checked" value="0"/>
            <label for="rn_SelectionInput_47_Incident.CustomFields.c.pertains_to_cafe_0">
            No                        </label>
                        </fieldset>
    </div>
        <div id="rn_SelectionInput_49" class="rn_SelectionInput rn_Input rn_Radio">
            <fieldset>
            <legend id="rn_SelectionInput_49_Label" class="rn_Label">
                Send to Franchise                            </legend>
                    <input type="radio" name="Incident.CustomFields.c.send_to_franchise" id="rn_SelectionInput_49_Incident.CustomFields.c.send_to_franchise_1"  value="1"/>
            <label for="rn_SelectionInput_49_Incident.CustomFields.c.send_to_franchise_1">
            Yes                        </label>
                    <input type="radio" name="Incident.CustomFields.c.send_to_franchise" id="rn_SelectionInput_49_Incident.CustomFields.c.send_to_franchise_0"  value="0"/>
            <label for="rn_SelectionInput_49_Incident.CustomFields.c.send_to_franchise_0">
            No                        </label>
                        </fieldset>
    </div>
        <div id="rn_SelectionInput_51" class="rn_SelectionInput rn_Input rn_Radio">
            <fieldset>
            <legend id="rn_SelectionInput_51_Label" class="rn_Label">
                Order Cancellation                            </legend>
                    <input type="radio" name="Incident.CustomFields.c.order_cancellation" id="rn_SelectionInput_51_Incident.CustomFields.c.order_cancellation_1"  value="1"/>
            <label for="rn_SelectionInput_51_Incident.CustomFields.c.order_cancellation_1">
            Yes                        </label>
                    <input type="radio" name="Incident.CustomFields.c.order_cancellation" id="rn_SelectionInput_51_Incident.CustomFields.c.order_cancellation_0"  value="0"/>
            <label for="rn_SelectionInput_51_Incident.CustomFields.c.order_cancellation_0">
            No                        </label>
                        </fieldset>
    </div>
        <div id="rn_SelectionInput_53" class="rn_SelectionInput rn_Input">
    <div id="rn_SelectionInput_53_LabelContainer">
        <label for="rn_SelectionInput_53_Incident.CustomFields.c.admin_workspace_selection" id="rn_SelectionInput_53_Label" class="rn_Label">Workspace selection                        </label>
    </div>
    <select id="rn_SelectionInput_53_Incident.CustomFields.c.admin_workspace_selection" name="Incident.CustomFields.c.admin_workspace_selection">
            <option value="">--</option>
                            <option value="598" >Customer Care Standard Agent</option>
                    <option value="599" >Gift Card Specialist</option>
                    <option value="600" >Cafe ReDirect Specialist</option>
                    <option value="601" >Preventative Analysis</option>
                    <option value="602" >Program Management</option>
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                    <option value="608" >eCommerce Issue</option>
                    <option value="611" >No Intended Sale</option>
                    <option value="613" >Removing Tax</option>
                    <option value="609" >Removing Tip</option>
                    <option value="612" >Service Issue</option>
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    <textarea id="rn_TextInput_63_Incident.CustomFields.c.passthrough_textarea" class="rn_TextArea" rows="7" cols="60" name="Incident.CustomFields.c.passthrough_textarea" maxlength='4000' placeholder=" "></textarea>
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        <input type="text" id="rn_TextInput_68_Contact.Name.Last" name="Contact.Name.Last" class="rn_Text" maxlength='80' required  placeholder=" "/>
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        Email Address                    <span class="rn_Required"> *</span><span class="rn_ScreenReaderOnly"> Required</span>
                                </label>
    </div>
        <input type="email" id="rn_TextInput_70_Contact.Emails.PRIMARY.Address" name="Contact.Emails.PRIMARY.Address" class="rn_Email" maxlength='80' required value='' placeholder=" "/>
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    <div id="rn_TextInput_74_LabelContainer">
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        MyPanera Card Number                            <span class="rn_Optional">Optional</span><span class="rn_ScreenReaderOnly"> Optional</span>
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        Please share a bit more detail. This will help us assist you more quickly.                    <span id="rn_ProductCategoryInput_76_RequiredLabel" class="rn_Required rn_Hidden"> *</span><span id="rn_ProductCategoryInput_76_ErrorLabel" class="rn_ErrorLabel">
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    <div id="rn_SelectionInput_79_LabelContainer">
        <label for="rn_SelectionInput_79_Incident.CustomFields.c.pertains_to_cafe" id="rn_SelectionInput_79_Label" class="rn_Label">Does your question pertain to a specific bakery-cafe?                        </label>
    </div>
            <input type="checkbox" id="rn_SelectionInput_79_Incident.CustomFields.c.pertains_to_cafe" name="Incident.CustomFields.c.pertains_to_cafe"  value="1"/>
            </div>
   </div>
    <!-- State Field =================================================== -->
    <div id="rn_HierarchyInput_80" class="rn_HierarchyInput rn_SelectionInput rn_Input rn_Hidden">
    <div id="rn_HierarchyInput_80_LabelContainer" class="">
        <label for="rn_HierarchyInput_80_Z.CafeInfo.CafeState.ID" id="rn_HierarchyInput_80_Label" class="rn_Label">                        </label>
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                    <option value="3" >AR</option>
                    <option value="4" >AZ</option>
                    <option value="5" >CA</option>
                    <option value="6" >CO</option>
                    <option value="7" >CT</option>
                    <option value="8" >DC</option>
                    <option value="9" >DE</option>
                    <option value="10" >FL</option>
                    <option value="11" >GA</option>
                    <option value="12" >IA</option>
                    <option value="13" >ID</option>
                    <option value="14" >IL</option>
                    <option value="15" >IN</option>
                    <option value="16" >KS</option>
                    <option value="17" >KY</option>
                    <option value="18" >LA</option>
                    <option value="19" >MA</option>
                    <option value="20" >MD</option>
                    <option value="21" >ME</option>
                    <option value="22" >MI</option>
                    <option value="23" >MN</option>
                    <option value="24" >MO</option>
                    <option value="25" >MS</option>
                    <option value="26" >NC</option>
                    <option value="27" >ND</option>
                    <option value="28" >NE</option>
                    <option value="29" >NH</option>
                    <option value="30" >NJ</option>
                    <option value="31" >NM</option>
                    <option value="33" >NV</option>
                    <option value="34" >NY</option>
                    <option value="35" >OH</option>
                    <option value="36" >OK</option>
                    <option value="37" >ON</option>
                    <option value="38" >OR</option>
                    <option value="39" >PA</option>
                    <option value="40" >RI</option>
                    <option value="41" >SC</option>
                    <option value="42" >SD</option>
                    <option value="43" >TN</option>
                    <option value="44" >TX</option>
                    <option value="45" >UT</option>
                    <option value="46" >VA</option>
                    <option value="47" >VT</option>
                    <option value="48" >WA</option>
                    <option value="49" >WI</option>
                    <option value="50" >WV</option>
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    <!-- City Field =================================================== -->
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            <option value="">City</option>
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    <!-- Location Field =================================================== -->
    <div id="rn_HierarchyInput_82" class="rn_HierarchyInput rn_SelectionInput rn_Input rn_Hidden">
    <div id="rn_HierarchyInput_82_LabelContainer" class="rn_Hidden">
        <label for="rn_HierarchyInput_82_X.Incident.CustomFields.CafeInfo.AssociatedCafe.ID" id="rn_HierarchyInput_82_Label" class="rn_Label">Bakery-Cafe                        </label>
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            <div id="rn_TextInput_83" class="rn_TextInput rn_TextInput rn_Input">
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        We’d love to hear your feedback. Please share your comments, questions or suggestions here.                    <span class="rn_Required"> *</span><span class="rn_ScreenReaderOnly"> Required</span>
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    <textarea id="rn_TextInput_83_Incident.Threads" class="rn_TextArea" rows="7" cols="60" name="Incident.Threads" maxlength='500' required placeholder="Your Feedback"></textarea>
<div class='rn_CharacterCount'>(&nbsp;<span id='rn_TextInput_83_CharacterCount'>500</span>&nbsp;)</div>
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RightNow.Interface.Constants = 
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n('RightNow.Widgets.DateInput').templates={"legend":"<% if (label) { %>  <%= label %> <% if (required) { %>  <span class=\"rn_Required\"><%= requiredMarkLabel %><\/span><span class=\"rn_ScreenReaderOnly\"><%= requiredLabel %><\/span>  <% } %> <% } %>"};
n('Custom.Widgets.input.TextInput').requires=["anim"];
n('RightNow.Widgets.ProductCategoryInput').templates={"label":"<%= label %><% if(requiredLevel) { %><span class=\"rn_Required\"> <%= requiredMarkLabel %><\/span><span id=\"rn_<%= instanceID %>_ErrorLabel\" class=\"rn_ErrorLabel\"> <span class=\"rn_ScreenReaderOnly\"> <%= requiredLabel %> <\/span><\/span><% } %>"};
n('RightNow.Widgets.ProductCategoryInput').requires=["panel","overlay","gallery-treeview","RightNowTreeView","RightNowTreeViewDialog","RightNowTreeViewDropdown"];
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n('RightNow.Widgets.FormSubmit').requires=["anim-scroll"];
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